The Radiologist-Speech Language Pathologist Disconnect

Speech Language Pathologists (SLPs) present themselves as experts in the identification and management of oropharyngeal dysphagia despite having no background in medical sciences or radiology. Training is almost entirely classroom/textbook-based or from others who are also poorly trained. The Videofluoroscopic Swallowing Study (VFSS) is used frequently, whether or not required, and is relied upon for recommendations for patient treatment that are then performed by physicians who believe in the expertise of SLPs.

Standards for the dynamics of swallowing were established in research by radiologists using barium alone. SLPs use barium mixed with food, which is not only of increased risk if aspirated, but is of a consistency unlike real food. Barium, if aspirated, is harmless and was used for years for bronchograms, injected directly into the lung mainly to identify tuberculosis. Mashed potatoes with barium is not even close to mashed potatoes alone, so the recommendations for types of food suitable for individual patients , based on materials used in VFSS , are invalid. Hospital food can be atrocious, but is unlikely to be improved by the addition of barium.[[{"type":"media","view_mode":"media_crop","fid":"28811","attributes":{"alt":"Irene Campbell-Taylor","class":"media-image media-image-right","id":"media_crop_9905308514310","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2945","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 248px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Irene Campbell-Taylor, MB ChB, PhD","typeof":"foaf:Image"}}]]

The claim that VFSS allows trials of compensatory strategies is affected by the same problem; the material used is totally unlike real food and we don’t eat in the half teaspoon or coffee spoon boluses used. Any indication of possible aspiration is often followed by a recommendation for thickened fluids, wrongly believed to prevent aspiration but known to cause dehydration leading to hypovolemia, orthostatic hypotension, falls, delirium, UTIs, constipation, decubiti, etc., especially in the elderly. Since we all aspirate some saliva every day, oral care is far more important than, say, aspiration of water.

Usually, lateral views only are done so that what’s going on in the other side of the mouth remains unknown. If AP views are omitted, one misses information, such as asymmetry of pharyngeal function, atrophy of the tongue, unilateral epiglottic failure, webs, and Zenker’s diverticula. Decisions about whether or not VFSS is necessary should depend on the results of the full clinical examination, which is seldom taught. Radiological examination would be required only if there were indications from the history such as tumor, diverticulum, web, or neuroleptic use with tardive dyskinesia among others.

The most alarming aspect of this situation is that very often the radiologist is not present during the study and signs the SLP’s report, sometimes due to the belief in its accuracy, but often because of a lack of interest in the area of oropharyngeal dysphagia. Morphological changes may be missed, sometimes with disastrous results. Inappropriate recommendations, especially for enteral feeding, are agreed to, diverticula and cervical osteophytes missed because the radiologist never looked at the study, which should always be reviewed in slow motion since the human eye is unable to identify all the elements of a rapid event such as swallowing.

It is suggested that the issues discussed here present a danger to the public that radiologists have a responsibility to correct.